Zeyu Xie, Zhuoru Liang, Yilin Xie, Guimei Zheng, Weiling Cao

Department of Pharmacy, The Third Affiliated Hospital (The Affiliated Luohu Hospital) of Shenzhen University, Shenzhen, Guangdong, 518001, People’s Republic of China

Correspondence: Guimei Zheng, Department of Pharmacy, The Third Affiliated Hospital (The Affiliated Luohu Hospital) of Shenzhen University, Shenzhen, Guangdong, 518001, People’s Republic of China, Email 13724349@qq.com Weiling Cao, Department of Pharmacy, The Third Affiliated Hospital (The Affiliated Luohu Hospital) of Shenzhen University, Shenzhen, Guangdong, 518001, People’s Republic of China, Email 752557163@qq.com

Purpose: Tirzepatide, a dual GLP-1/GIP agonist, shows promise for weight loss, but its safety compared to GLP-1 receptor agonists requires (liraglutide, semaglutide) clarification for clinical decision-making. This systematic review evaluates their safety profiles in patients with obesity or overweight.
Methods: We conducted a PRISMA-compliant systematic review (PROSPERO: CRD42024576314) of RCTs from PubMed, Embase, and Cochrane (inception to August 20, 2024). Adults with BMI ≥ 27 kg/m² (≥ 25 kg/m² for Asians) receiving GLP-1/GIP dual agonists (tirzepatide 10 or 15 mg) and GLP-1 receptor agonists (semaglutide 2.4 mg and liraglutide 3.0 mg) were included. Network meta-analysis (NMA) was conducted by using odds ratios with 95% CIs. Primary outcomes were adverse events (AEs) and serious AEs. NMA was performed using Stata 16.1.
Results: This network meta-analysis included 19 randomized controlled trials (13,529 participants). Liraglutide 3.0 mg significantly increased the incidence of any adverse events (OR = 1.53– 2.00) compared to semaglutide and tirzepatide, while tirzepatide showed a higher severe hypoglycemia risk (< 54 mg/dL). Notably, GLP-1/GIP dual agonists demonstrated superior safety profiles in neoplasms (vs liraglutide: OR = 5.15 [1.28– 20.74]; vs semaglutide: OR = 3.55 [1.10– 11.54]) and respiratory infections/nasopharyngitis, suggesting enhanced anti-inflammatory effects. GLP-1 agonists had fewer diarrhea and injection-site reactions but higher abdominal pain/dyspepsia rates. Subgroup analyses further revealed that non-T2DM patients had a significantly higher incidence of adverse events compared to T2DM patients (P < 0.05), while no significant associations were observed with race, BMI, or treatment duration. Sensitivity analyses confirmed robustness and funnel plots indicated no publication bias.
Conclusion: Liraglutide 3.0 mg was associated with higher overall adverse events, while tirzepatide (10 or 15 mg) showed increased severe hypoglycemia and injection-site reactions risk but superior anti-inflammatory and anti-neoplasm effects compared to GLP-1 mono-agonists. These findings highlight therapy-specific safety patterns critical for personalized treatment selection.

Keywords: GLP-1 receptor agonist, GLP-1/GIP dual receptor agonists, tirzepatide, weight loss, safety, systematic review